Provider Demographics
NPI:1174710750
Name:PHYSICIANS HOSPITAL, LLC
Entity type:Organization
Organization Name:PHYSICIANS HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL SERVICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-546-1911
Mailing Address - Street 1:1625 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-7103
Mailing Address - Country:US
Mailing Address - Phone:574-255-1400
Mailing Address - Fax:
Practice Address - Street 1:1625 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-7103
Practice Address - Country:US
Practice Address - Phone:574-255-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN080056581282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN152026Medicare Oscar/Certification